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  • 90 Day CCauth

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    Kristi Fish
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    Kristi Fish provides a credit card authorization form for monthly health coaching services. The form allows a client to provide their credit card information and authorize Kristi to charge $199 per month for 2 months, totaling $598, for health coaching services. The payment agreement remains in effect until services are completed or ended by client request. The client signs the form to authorize the credit card charges.

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    90dayCCauth

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    Kristi Fish provides a credit card authorization form for monthly health coaching services. The form allows a client to provide their credit card information and authorize Kristi to charge $199 per month for 2 months, totaling $598, for health coaching services. The payment agreement remains in effect until services are completed or ended by client request. The client signs the form to authorize the credit card charges.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    21 views1 page

    90 Day CCauth

    Uploaded by

    Kristi Fish
    Kristi Fish provides a credit card authorization form for monthly health coaching services. The form allows a client to provide their credit card information and authorize Kristi to charge $199 per month for 2 months, totaling $598, for health coaching services. The payment agreement remains in effect until services are completed or ended by client request. The client signs the form to authorize the credit card charges.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 1

    Kristi M.

    Fish, AADP, CHC, MSEd


    518.928.8313
    kristi@healthmadesimple.co
    www.healthmadesimple.co

    Credit Card Authorization Form


    I, __________________________, hereby authorize _____________________to charge the
    following credit card account in the amount shown below for monthly health coaching services.
    This payment agreement will be in effect until services have been completed or are ended by
    request of the client either verbally or in writing.
    CREDIT CARD INFORMATION:
    CARD TYPE: !VISA ! !

    MASTERCARD!

    Card Number: !!

    _________________________________________

    Card Verification # !

    ________________

    Expiration Date:!

    _______/_________

    Name on Card:! !

    _________________________________________

    Billing Street Address:! !

    _________________________________________

    AMEX!

    DISCOVER

    City __________________________State ______Zip____________

    Email Address:! !

    _______________________________________

    Amount
    $200.00

    Deposit

    $199.00

    per month for 2 months

    $598.00

    Total Amount

    Cardholders Signature: _____________________________________


    Thank you.

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